"Medicine is a social science, and politics is nothing else but medicine on a large scale"—Rudolf Virchow

September 22, 2018

Word is moving on Twitter about an undiagnosed outbreak in Sudan's Kassala state. The Sudanese online media are few, and I have no idea how reliable they are. But here's a report from Al-Rakubah on a similar outbreak in North Darfur: Unknown fever infects dozens of citizens in Al-Fasher. The Google translation, for what it's worth:

A medical source familiar with the failure to disclose the injury of dozens of citizens of an unknown fever hit large parts of the neighborhoods of the city of El Fasher, capital of the state of North Darfur, causing confusion among the medical staff working in the educational hospital in Fasher.

The medical source, who declined to be named, said that Al-Fashir Teaching Hospital recorded on Friday night about 90 cases of unidentified fever similar to what appeared in the state of Kassala last days.

"The wounded are from different neighborhoods of the city, with ages ranging from 20 to 25 years of both sexes."

He said that the hospital administration had taken the necessary action for a number of the injured, where it was later found that among them were infected with malaria, while it was not clear why the other diets.

Some of them had left the hospital to their homes after undergoing medical checkups, and activists through social networking sites called on state authorities to take care of the unknown feces and immediately investigate them as soon as possible.

Update: As the map shows, Al Fasher is far to the west to Kassala, so this outbreak may be spreading by people leaving Kassala. And such people may be going all over Sudan, or into other countries. None of these countries have robust healthcare systems or much media freedom, so whatever the disease may be, it's likely to be widespread before gaining official notice.

PHNOM PENH, Cambodia — Beat Richner, a Swiss pediatrician who opened a network of children’s hospitals in Cambodia at a time when quality health care was all but nonexistent in that country, died on Sept. 9 in Zurich. He was 71.

His death was confirmed by Dr. Denis Laurent, his longtime deputy director at the Kantha Bopha Children’s Hospitals in Cambodia. No cause was given. Dr. Richner had been treated for a degenerative brain disease.

He arrived in Phnom Penh, the capital of Cambodia, in 1992 to take over a 60-bed pediatric hospital in a country ravaged by civil war during the Khmer Rouge era, mired in poverty and rife with corruption.

His facility became known as the Angel Hospital because it treated anyone, no matter how poor, while providing care at a level many did not believe possible in Cambodia.

Through fund-raising and fierce advocacy, he gradually turned the building into a network of five medical centers in two cities, Phnom Penh and Siem Reap. They now treat about one million patients a year.

Dr. Richner, whose motto was “One child, one life,” was beloved by many Cambodians, who saw his devotion to patient care as a corrective to their government’s failures in helping the sick and even disregard for human life.

But he could be irascible and uncompromising and often clashed with international public health experts, some of whom found his efforts ego-driven and unsustainable.

In one instance he took out newspaper advertisements accusing the World Health Organization of “passive genocide,” saying it emphasized adhering to rules and protocols over saving lives. He dared the organization to donate its entire annual budget to create 200 of his hospitals around the world. (It did not.)

“For a poverty-stricken child who needs to be healed and saved, the theoretical and ideological question of sustainability that the experts in their offices are concerned about is absolutely meaningless,” Dr. Richner wrote in 1998.

He had almost no personal life or interests outside of medicine, with one exception: He moonlighted as a cellist, giving performances as an alter ego named Beatocello, whom he described as “a poetic and musical comedian or clown.”

In this guise, he would play soulful renditions of Bach’s cello suites and his own original compositions for tourists in exchange for donations, which he then poured back into his hospitals.

“His life was very limited and connected to only two things,” said Dr. Ky Santy, who became the director of Kantha Bopha after Dr. Richner stepped down for health reasons last year. “First, to the daily life of the hospital; and second, to the cello.”

The epidemiological situation of the Ebola Virus Disease dated 21 September 2018:

• A total of 147 cases of haemorrhagic fever were reported in the region, of which 116 were confirmed and 31 were probable.

• Of the 116 confirmed, 68 died and 40 are cured.

• 13 suspected cases are under investigation.

• No new confirmed cases notified.

• No new deaths.

• 1 new person healed in Beni.

Remarks:

• To avoid that the total number of cases varies (up or down) daily, the suspect cases have been placed in a separate category. Thus, suspect cases with positive laboratory tests will be added to the confirmed category, while negative ones (non-cases) will be removed from the table.

• The category of probable cases includes all reported deaths for which it was not possible to obtain biological samples for laboratory confirmation. The investigations will determine whether these deaths are related to the epidemic or not.

News of the response

Social mobilization

• On Saturday, September 22, 2018, nearly 500 nurses from the health zones of Beni, Oicha, Mabalako, Masereka and Vuovu marched in the city of Beni to show their support for the response to the epidemic of Ebola. They went to the town hall of the city of Beni where they held a conference on the prevention of intra-hospital contamination by Ebola virus disease. As a result of the large number of nurses who became infected and died of Ebola during this epidemic, nurses in the affected areas pledged to be more compliant with hospital infection prevention and control measures to avoid this kind of infection. tragedy in the future. In addition, they handed to the Coordinator of the Riposte, Dr Ndjoloko Tambwe Bathe,

Vaccination

• The vaccination of the first contacts of the confirmed case of Tchomia began this Saturday, September 22, 2018. So far, 56 contacts have already voluntarily registered with vaccination teams.

• Since the start of vaccination on August 8, 2018, 11,109 people have been vaccinated , including 4,014 in Mabalako, 3,536 in Beni, 1,632 in Mandima, 734 in Butembo•, 573 in Katwa•, 270 in Masereka, 164 in Komanda, 121 in Oicha and 65 in Kinshasa (medical staff to deploy).

* The health zones of Butembo and Katwa are two neighboring areas in the town of Butembo. Given the regular movement of contacts in these areas, it is sometimes necessary to reclassify vaccinated contacts back to their original health area after verification of vaccination data. This explains why the cumulative number of people vaccinated in Butembo is lower than the cumulation reported in the previous bulletin. These contacts have been reclassified to Katwa.

Health officials in Bunyoro sub region have intensified their health surveillance network following the reported case of Ebola at the Tchomia landing site in Ituri Province on the shores of Lake Albert. The Tchomia landing site in Ituri is the closest landing site to some districts in Bunyoro.

On Friday, Ituri province Vice Governor Keta Upar said in a statement that the latest Ebola case had been reported in Tchomia on the shores of Lake Albert.

Tchomia is one of the busiest fish markets in Eastern Democratic Republic of Congo that attracts several Ugandan businessmen from the landing sites of Butiaba, Walukoba, Kijangi, Kaiso,Sebigoro, Nkondo, Ndaiga, Ntoroko, Kyehoro and Fofo from the districts of Hoima, Buliisa, Kikuube, Ntoroko and Kagadi to transact fish business in the market.

Ugandan businessmen cross to Tchomia Market on a weekly basis posing a big threat that the disease outbreak could easily be reported in Uganda if the movements of the businessmen are not regulated. Tchoima fish market operates every Thursday.

Dr Fredrick Byenume, the Hoima district Health Inspector warns the public to be vigilant and report any suspicious cases to the nearby trained health personnel deployed along the shores of Lake Albert.

Byenume told URN on Saturday that the district is currently training 70 surveillance officers who are to be deployed along all the landing sites in the district to carry out surveillance services.

He says next week the district health department will embark on training of case management personnel who will be equipped with all the necessary techniques of handling Ebola cases.

«14 days after the outbreak of the epidemic we returned to the starting point ». These are the words to love those with which the mayor of Montichiari, Mario Fraccaro, has communicated via Facebook the results of the investigations conducted by ATS that exclude the presence of legionella in the waters of the cooling tower west of the Montichiari paper mill.

One of the three in which the first findings of the same ATS had identified the bacterium, so as to indicate by the regional health authorities that precisely in the towers of three companies was to identify the cause of the epidemic. And if the Montichiari paper mill is so cleared in full, the similar insights on the other two companies involved - respectively in Calvisano and Carpenedolo - will arrive on Monday.

Even if they were negative, it would be really all have to be redone. The question remains: what is the cause of the epidemic , which has 468 cases of pneumonia, an out-of-scale figure for the period, with 45 positivities ascertained to legionella?

Not the Chiese for the same ATS, which also in the sampling of the waters of the river that flows along many of the countries at the center of the contagion has found traces: "The bacterium is present in nature, especially in water, but the human contagion occurs through nebulized droplets, while also for irrigation purposes, the waters of the Chiese are used only for flow, not for sprinkling ».

It is the world’s deadliest infectious disease, killing almost 2 million people a year – more than HIV and malaria combined – but the fight against tuberculosis (TB) is still severely underfunded and neglected by politicians and decision-makers, experts warn.

TB is both preventable and curable, but remains a significant public health risk and caused more than 10 million people to fall ill in 2016. This month, the United Nations general assembly will hold the first high-level meeting on the TB crisis, putting a spotlight on the disease 25 years after it was declared a global emergency. Ahead of the event, the Guardian held a roundtable discussion with experts in the field, chaired by health editor Sarah Boseley and supported by the Stop TB Partnership, to discuss the barriers to fighting the disease.

It is inextricably linked with poverty, with more than 95% of deaths from TB taking place in low- and middle-income countries, which is why action has so far been “inadequate”, said Peter Sands, executive director of the Global Fund to fight Aids, TB and Malaria.

“Most people in places with money and power don’t think about TB at all,” he said. “People think TB was something sorted out a long time ago. Because they don’t have much resourcing for it, very few politicians are making courageous decisions.”

“There’s a lack of political will, and it’s exacerbated by the fact that TB is a disease of the poor,” said Nick Herbert, MP for Arundel and South Downs and co-chair of the all party parliamentary group on global TB and the Global TB Caucus.

Research has found programmes to tackle poverty could be just as effective in the fight against TB as medicines and vaccines. Bill Lynn, a clinician for London North West University NHS healthcare trust, and Ruth Sherratt, senior international programme officer at TB Alert, both noted the complex social and economic factors driving the problem.

“It is a disease linked with poverty, and populations that are physically, socially and culturally hard to reach,” said Sherratt. “We need to make sure the funding addresses those issues as well.”

The new president of the Canadian Medical Association is calling on politicians to have an "open and courageous" debate about decriminalizing opioids in the face of a nationwide overdose crisis.

"I think the time for having those conversations is now," Dr. Gigi Osler told the CBC's Chris Hall in an interview airing Saturday on CBC Radio's The House.

"With the opioid crisis at the stage it is now, it's probably worth it to have that open and courageous conversation, to look at whether decriminalization would be part of the solution or would it contribute to the problem."

Osler said she uses the word "courageous" to describe such a debate because Canadian society's prevailing attitudes toward substance abuse — particularly of opioids — make such a conversation politically perilous.

"There's still a lot of stigma associated with people who have an opioid use disorder," she said. "To decriminalize opioids almost means for some people they need to accept it."

At least 1,036 Canadians died in the first three months of this year of what appeared to be opioid overdoses, raising the opioid epidemic's national death toll to more than 8,000 people since January 2016, according to newly released government figures.

"The opioid crisis certainly is a huge public health crisis right now," Osler said, echoing Montreal and Toronto's health departments, which are urging the federal government to treat drug use as a public health issue rather than a criminal one.

Trudeau: decriminalizing opioids 'not part of the plan'

In the House of Commons on Wednesday, discussing the Liberals' approach to the opioid crisis, Prime Minister Justin Trudeau said his government "will not treat this as a criminal issue" — a statement his health minister, Ginette Petitpas Taylor, has echoed.

But for now, the door to decriminalization remains firmly shut. At a town hall in February, Trudeau said lifting criminal penalties for illegal opioid use is "not a step that Canada is looking at taking at this point."

September 21, 2018

The ECDC Communicable Disease Threats Report (CDTR) is a weekly bulletin for epidemiologists and health professionals on active public health threats. This issue covers the period 16-22 September 2018 and includes updates on West Nile virus, Ebola virus disease, cholera, monkeypox and Legionnaires' disease.

The epidemiological situation of the Ebola Virus Disease dated September 20, 2018:

• A total of 147 cases of haemorrhagic fever were reported in the region, of which 116 were confirmed and 31 were probable.

• Of the 116 confirmed, 68 died and 39 are cured.

• 11 suspected cases are under investigation.

• 4 new confirmed cases including 3 in Beni and 1 in Tshomia (Ituri).

• 2 confirmed cases, including 1 in Beni and 1 in Tshomia (Ituri).

Remarks:

To avoid that the total number of cases varies (up or down) daily, the suspect cases have been placed in a separate category. Thus, suspect cases with positive laboratory tests will be added to the confirmed category, while negative ones (non-cases) will be removed from the table.

• The category of probable cases includes all reported deaths for which it was not possible to obtain biological samples for laboratory confirmation. The investigations will determine whether these deaths are related to the epidemic or not.

News of the response

Epidemiological surveillance

• A new confirmed case has been reported in the Tshomia Health Zone, 50 km from Bunia, Ituri province. This case was a known contact of the first confirmed case reported in the district of Ndindi, in the city of Beni. It is around this community death that the pockets of resistance in this neighborhood crystallized. After the death and unsecured burial of this woman in Ndindi, some of her family members refused to cooperate with the response teams, resulting in several confirmed cases and deaths in the same family. When these people started to become symptomatic, they hid or fled to other health areas, including Mabalako, Masereka, Butembo and Tshomia.

• So, In all these areas, the coordination sent intervention teams in the first 24 to 36 hours of the notification to quickly identify and vaccinate the contacts around these different cases. These rapid interventions are necessary to rapidly break the chain of transmission related to Ndindi's resistance.

• On Friday, September 21, 2018, a joint team was deployed to the Tshomia Health Zone. This mixed team consisted of vaccinators, epidemiologists, psychologists, communicators, experts in infection prevention and control, an emergency physician and a logistician.

• Since the beginning of vaccination on August 8, 2018, 10,944 people have been vaccinated , including 3,980 in Mabalako, 3,455 in Beni, 1,632 in Mandima, 844 in Butembo, 413 in Katwa, 270 in Masereka, 164 in Komanda, 121 in Oicha and 65 in Kinshasa (medical staff to deploy).

A woman died on Thursday, September 20th, at the general reference hospital of Tchomia, sixty kilometers south of Bunia (Ituri). The vice governor of Ituri province, Pacific Keta, says the results of the samples sent to the laboratory of the National Institute for Biological Research (INRB), based in Beni, North Kivu, are positive.

"I want to inform the people of Ituri in general and Tchomia in particular about the death occurred Thursday, September 20 at the general hospital around 8 o'clock in the morning. It is Mrs. Espérance Kiakimua Kapanza, 32 years old, " says Pacifique Keta.

He said that the victim participated in the burials of Ebola cases in Beni of two patients.

"She [Hope Kiakimua] was followed by the Beni medical team as a suspected case of contact. She refused the vaccination, disappeared from Beni, then went to Komanda but was not found," said the vice-governor.

A joint delegation from the World Health Organization (WHO) and the Provincial Health Division visited Tchomia.

The team aims to identify and vaccinate all those who have come into contact with the patient, strengthen infection prevention and control measures, and train health providers to deal with reported cases.

Google Maps doesn't have Tchomia in its memory, but the town would presumably be just to the south of Geti and less than two hours' drive from Bunia.

Update: Tchomia is also, according to this Reuters report, very close to the Uganda border and on the shore of Lake Albert. Thanks to Helen Branswell for tweeting the link to it.